ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia 1800 688 640 claims phone 1800 815 675 customer service +61 (0)2 9231 3697 claims fax A&HClaims.AU@acegroup.com www.aceinsurance.com.au Travel Insurance Report Form IMPORTANT INFORMATION Please ensure this Form is completed in all Parts applicable to your claim. The Privacy Consent must be completed for all claims. Supporting documentation required is detailed below each Part. The issue acceptance of this Form does not constitute an admission of liability by the Company or a waiver of its rights. Name of PolicyholderInsured Name of Claimant (MrMrsMissMs) Policy Number Credit Card Number (if applicable) Address Policy Claimant Details ALL QUESTIONS IN THIS SECTION MUST BE ANSWERED Telephone Home ( ) Business ( ) Mobile Email Address Date of Birth Occupation Travel Agent Date of Booking Travel Arrangements Date of Departure Date of Return Electronic Funds Transfer Details Following ACE approval of your claim, should you wish to have your claim benefits transferred directly into your bank account, please provide the following details: Name of Financial Institution Account Holder s Name: BSB Number: Account Number: GST Information (For Australian Claims Only) (a) Are you registered for GST Purposes? Yes No (b) (c) What is your Australian Business Number (ABN)? Have you claimed or are you entitled to claim an Input Tax Credit (ITC) in respect to the GST paid on the insurance policy under which this claim is being made? Yes No (d) IF YES, what percentage of the GST did you claim or are you entitled to claim? % (if the GST paid your ITC entitlement are the same amount, the answer to this question is 100%) One of the ACE Group of Insurance & Reinsurance Companies Document No: BTA 001 (Aug 2009) ACE Insurance Limited ABN 23 001 642 020 AFSL No: 239687
1. The Original TicketsVouchers if a refund is not obtainable. 2. Doctor shospital Certificate specifying exact nature of condition suffered by InjuredSick person. 3. Letter from Travel Agent verifying total cost of journey, value of unused portion of journey, cancellation charges incurred total amount of refund received. What was the reason you could not commence or complete your proposed journey? Was the cancellation as a result of InjurySickness to yourself? Yes No Was the cancellation as a result of InjurySickness to some other relative or person as defined in the Policy? Yes No If so - Name Address Relationship Age Nature of complaint preventing travel Date of First Medical Treatment Has the InjuredSick person had a similar condition in the past? Yes No Name Address of Patient s normal Doctor Date you advised Travel Agent to cancel bookings Amount of deposit paid date paid $ Date Balance of full fare date paid $ Date Value of forfeited portion of journey (if applicable) $ Refund received on cancellation $ Full amount being claimed $ Were any alternative arrangements offered? If so, give details Did you accept any of the alternative arrangements? Yes No What additional fares did you incur as a result of alterations to the arrangement?
1. Original Doctor shospital accounts receipts together with details relating to medical benefit refunds. 2. Original Doctor s Certificate verifying nature of complaint suffered by you. Type of Injury or Sickness Date of Accident or commencement of Sickness If injury - Give full details of Accident Date of First Medical Consultation Name of Doctor or Hospital Details of other treatment by DoctorsHospital Dates in Hospital Admitted ampm Discharged ampm List the Country the currency of the Country in which you incurred the medical costs Country: Country: Currency: Currency: Total Amount: Total Amount: Have you ever suffered from the same or similar complaint in the past? Yes No If Yes, give details, dates names addresses of treating physicians Name Address of usual family doctor How long has the doctor been known to the patient? Are you a member of a Private Health Insurance Fund, e.g. Medibank? Yes No If Yes, please supply name of fund PLEASE NOTE: All medical accounts must first be lodged with your Private Health Fund, if applicable. The policy is only able to consider Non-Medicare claimable expenses.
(For additional travel accommodation incurred during the journey) 1. Receipts or Tickets relating to additional expenses incurred. 2. Doctor shospital Certificate specifying exact nature of condition suffered by InjuredSick person. 3. Letter from Travel Agent or carrier verifying reason for additional expenses or any refund applicable. Dates Expenses Incurred Reason for incurring additional travel or accommodation expenses List the Country the Currency of the Country in which you incurred the costs Country: Currency: List specifically the additional TRAVEL expenses Details Amount TOTAL List specifically the additional ACCOMMODATION expenses Details Amount TOTAL Were these expenses incurred as a result of Injury or Sickness as claimed in Part 1? Yes No If these expenses were incurred as a result of Injury or Sickness to any other person, please give details of cause, name, address, age of person relationship to you Cause Name Address Age Relationship
1. Report or letter from Authority (e.g. Police, Airline) regarding the loss. 2. Receipts Guarantee Certificates, Instruction Manuals, Valuation Certificates, Bankcard or Credit Card Vouchers or other proof of purchase for items claims. 3. Bank Statements, transaction receipts or other proof of cash claimed. 4. Quotations for replacement of items claimed. Give full details of how losses, damage or thefts occurred: (Detail each event) Date lossdamage occurred Time ampm Date lossdamage reported Time ampm Lossdamage reported to (Police, Airline or other authority) Name Were articles lostdamaged by a Carrier? (e.g. Airline) Yes No Name Have you yet lodged a claim or complaint against any CarrierAirline or other Authority or against any individual Airline: Claim No. responsible for the loss or damage to your property? If so, give details attach copies of correspondence. If not, you should proceed to claim with your CarrierAirline before submitting your claim to ACE What Action was taken to recover lost items? Are any of the items covered by other insurance? Yes No If - Which company Policy Number Were all the missing articles your property? Yes No If not, give details Other comments (if necessary) Description size of suitcase in which missing goods carried Full details of articles claimed (include value of cases) Name address from whom goods were purchased Original Date of Purchase Original Purchase Price Replacement Amount Claimed Aust. $ Remarks
1. The original Policy Document. 2. Certified copy of Death Certificate. 3. Copy of Coroner s Depositions Findings (if applicable). 4. Certified copy of Birth Certificate. What was the cause of death? When did the accident occur? Time ampm Was a coronial inquest held Yes No or is one to be held? If so give details Name Address of usual family doctor: How long has the doctor been known to the patient? 1. Letters or Dems of a claim made against you. 2. Quotations or receipts in support of a claim made against you. Bodily Injury - Provide relevant details - name, address, phone number email address of Injured Party details of Injury Damage to Property - List all Property Damage together with name, address, phone number email address of Party claiming damage against you Is the Injury or Damage related to a travelling companion? Yes No Do you consider you were at fault? (If so, why) 1. The Rental Agreement. 2. Notice from the Rental Company in respect of the excess or deductible. 3. Documentation evidencing payment of excess or deductible. 4. A copy of the Rental Vehicle Repair Invoice from the Hire Company. Date Of Loss Value of ExcessLDW $ Please provide a full description of the circumstances of the incident giving rise to the claim:
ACE Insurance Limited Claim Privacy Consent, Medical Authority Declaration Claim Privacy Consent ACE Insurance Limited (ACE) collects, uses retains your personal information only in accordance with Australia s National Privacy Principles. A copy of our Privacy Policy is available on our website at www.aceinsurance.com.au or by contacting our customer relations team on 1800 815 675. Your personal information will be used by ACE, or any third party that ACE provides the information to, for the purpose of assessing your claim or your entitlement to benefits, if the claim is accepted, for administration of the claim for planning, product development research purposes. Your personal information may include: Any information provided in relation to your claim; Any information that is health information or sensitive information, including without limitation your medical history, any treatment received by you any medication taken or prescribed for you (at any time) or your Health Insurance claims history, including Medicare; Any other personal information that you may provide to ACE or its third party contractors; Any information relating to any insurance policy on your life, including terms conditions claims history; Details Details of of your your employment employment including including position, position, period period of of employment, employment, remuneration, remuneration, hours hours worked worked duties duties performed performed (at (at any any time); time); Any Any information information relating relating to to your your income, income, assets, assets, liabilities liabilities solvency; solvency; Any information from third persons who may have information relevant to your eligibility to receive a benefit, or your entitlement to receive an Any information from third persons who may have information relevant to your eligibility to receive benefit, or your entitlement to receive an ongoing benefit. ongoing benefit. To process your claim ACE may need to collect your personal information from third parties such as your insurance broker, claims reference services, government To process your organisations claim ACE (for may example need to collect social security your personal agencies information taxation from offices), third parties your such doctor as or your other insurance health service broker, claims provider, reference any forensic services, accountant government retained organisations by ACE, (for your example employers social security (past agencies present), or your taxation accountant offices), your any doctor businesses or other which health provide service information provider, any about forensic the accountant commercial activities retained by of ACE, persons your or, employers if you are, (past or have present), been, bankrupt your accountant the trustee of any your businesses estate (the which Parties ). provide information about the commercial activities of persons or, if you are, or have been, bankrupt the trustee of your estate (the Parties ). ACE may disclose your personal information, including health sensitive information, to third parties, including contractors contracted service providers engaged by us to deliver our services (such as assessors), other companies in the ACE group, other insurers, our reinsurers, government ACE may agencies disclose including your personal the police information, (where we including are compelled health to by sensitive law). These information, third parties to third may parties, be located including outside contractors Australia. ACE contracted may also service disclose your providers personal engaged information by us to to deliver witnesses our services in respect (such to your as assessors), claim. other companies in the ACE group, other insurers, our reinsurers, government agencies including the police (where we are compelled to by law). These third parties may be located outside Australia. ACE may also disclose your If personal you have information a complaint to witnesses or want more in respect information to your about claim. how ACE is managing your personal information, please contact the Privacy Officer, ACE Insurance Limited, GPO Box 4907, Sydney NSW 2001, Tel: +61 2 9335 3200 or email Privacy.AU@acegroup.com If you do not consent to the terms of this Privacy Consent Medical Authority or revoke your consent, ACE may not be able to process or assess your If you do not consent to the terms of this Privacy Consent Medical Authority or revoke your consent, ACE may not be able to process or assess claim. your claim. If you would like to access a copy of your personal information, or or to to correct or or update your your personal information, please please contact contact our our customer customer relations relations team 1800 team 815 on 1800 675 or 815 email 675 customer.relations@acegroup.com. or email CustomerService.AUNZ@acegroup.com. Medical Authority Declaration I underst that by investigating my claim or by accepting proofs of my claim, ACE has made no acceptance of liability, nor waived any of its rights in defence of any claim arising under the policy. I agree to ACE using disclosing my personal information pursuant to ACE s Privacy Policy this document. In the event of any conflict between the documents, this document will be determinative. This consent remains valid unless I alter or revoke it by giving written notice to ACE s privacy officer. I authorise any person or entity, including but not limited to the Parties referred to above, to provide to ACE such personal information (including health information) as ACE is its absolute discretion considers relevant for its assessment of my claim or my entitlement to benefits. I will use my best endeavours render all reasonable assistance co-operation to ACE in the assessment of my claim. I confirm that any information that I supply will be true correct that I will not withhold any information likely to affect the acceptance or hling of my claim. I underst that my claim may be denied if the information supplied is untrue, or I have not revealed all relevant facts. I appoint ACE to do everything necessary or expedient to give effect to the transactions contemplated by the consents authorisations in this document to execute, on my behalf, any documents or to do such acts required to give effect to this Privacy Consent Medical Authority. Signature of Claimant Date Name of Claimant Signature of Witness Date Name of Witness